UARS: A Critical Link to Optimizing PAP Therapy Results

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Lots to talk about, but let's cut to the chase and clear up the pressing singular confusion about bilevel. Read the abstract and if you are so inclined visit PubMed and you'll find that the whole article is there for free.

1: Chest. 1990 Aug;98(2):317-24.

Obstructive sleep apnea treated by independently adjusted inspiratory and expiratory positive airway pressures via nasal mask. Physiologic and clinical implications. Sanders MH, Kern N.

Division of Pulmonary and Critical Care Medicine, University of Pittsburgh School of Medicine.

Treatment of obstructive sleep apnea with nasal continuous positive airway pressure mandates simultaneous increases of both inspiratory and expiratory positive airway pressures to eliminate apneas as well as nonapneic oxyhemoglobin desaturation events. We hypothesized that the forces acting to collapse the upper airway during inspiration and expiration are of different magnitudes and that obstructive sleep-disordered breathing events (including apneas, hypopneas and nonapneic desaturation events) could be eliminated at lower levels of EPAP than IPAP. To test these hypotheses, a device was built that allows the independent adjustment of EPAP and IPAP (nasal BiPAP). Our data support the hypotheses that expiratory phase events are important in the pathogenesis of OSA and that there are differences in the magnitudes of the forces destabilizing the upper airway during inspiration and expiration. Finally, applying these concepts, we have shown that by using a device that permits independent adjustment of EPAP and IPAP, obstructive sleep-disordered breathing can be eliminated at lower levels of expiratory airway pressure compared with conventional nasal CPAP therapy. This may reduce the adverse effects associated with nasal CPAP therapy and improve long-term therapeutic compliance.

So, to put it diplomatically, the notion that bilevel doesn't have a potential role in managing SDB or OSA with greater precision is quite wide of the mark.

Also, harken back to the discrepancy between science and consensus medicine. Here is it is black and white 17 years ago...a study showing advantages to bilevel, yet as we can tell from the threads and from most people's experiences in sleep labs, this knowledge has not diffused into the medical community.

Rest Wishes,

The low pressure setting (EPAP) in a bilevel is there for patient's comfort and does absolutely nothing to improve OSA treatment. At worst, it can even represent a weak spot that risks airway collapse.

Well--I just got titrated for BiPAP last night after discussions with Dr C. Guilleminault yesterday. My complaint was exhalation. We looked at my Encore reports for the month of August and the month of November. I was relieved to hear he did think I should go on BiPAP; dismayed to find out that the titration was going to start with an EP at my current average pressure of 9; and surprised that the BiPAP was so comfortable at the ending IP at 15 and EP at 11. I was much more comfortable throughout the respiratory cycle. I looking forward to seeing the report.

This does not decrease my pressure and I'm assuming the higher pressure will improve my OSA treatment. Dr Guilleminault, the tech at the lab, and Rested Gal all said about the same thing about eliminating apneas to set the EP then setting the IP by going after hypopneas and FLs. Why the expiratory phase was more comfortable for me is something I can't explain. The other thing I noticed was that when I'm at 12 on my CPAP my interface leaks more-even at 15 last night I did not have the same problem. Only one night--hopefully things will stay this way.

I suspect you can change the settings for the bipap, do you get a software with that to analyse your breathing?Or each change in setting would need a sleep study done. I read in some earlier post there is no data for the PB 425 bipap.

Thank you for the quoted article in your post, Dr. Krakow. It really helps to substantiate my point.

The article shows that we can get away with a lower EPAP in treating OSA on exhaling and thus improving long-term patients' compliance.

It says nothing about the lower EPAP doing anything wonderful toward propping up that problematic airway.

As such: Bilevels give comfort? yes. Better than APAP or CPAP in treating OSA? Need I repeat the obvious?

Note: I really don't care to be argumentative. It's just that right now I simply couldn't stand seeing my fellow cpap'ers being kept in the fog one more time in this issue regarding bilevels by the establishment.

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP, APAP

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khvn wrote:Thank you for the quoted article in your post, Dr. Krakow. It really helps to substantiate my point.

The article shows that we can get away with a lower EPAP in treating OSA on exhaling and thus improving long-term patients' compliance.

It says nothing about the lower EPAP doing anything wonderful toward propping up that problematic airway.

As such: Bilevels give comfort? yes. Better than APAP or CPAP in treating OSA? Need I repeat the obvious?

Note: I really don't care to be argumentative. It's just that right now I simply couldn't stand seeing my fellow cpap'ers being kept in the fog one more time in this issue regarding bilevels by the establishment.

You are the only one in the fog here ... get some sleep and maybe it will sink in tomorrow

On the chance that it's not "trolling", but is truly a misunderstanding about what the EPAP pressure in a bilevel machine is for....

khvn wrote:Thanks for all the feedback, folks. But no one really addresses my real beef in this thread! And that is:

The low pressure setting (EPAP) in a bilevel is there for patient's comfort and does absolutely nothing to improve OSA treatment. At worst, it can even represent a weak spot that risks airway collapse. As such, for treating OSA, bilevels possess nothing more special or better than APAPs or even straight CPAPs.

This is contrary to claim that has been made about bilevels!

You're still not understanding that the "low pressure setting (EPAP) in a bilevel" is NOT there "just for patient's comfort".

EPAP is there for treatment purposes.

The fact that EPAP can also provide comfort during treatment is secondary to its main purpose. The purpose of EPAP to keep the airway open during exhalation and during any pause at the end of exhale. To keep the throat from collapsing so that a person can START to inhale again.

You are also not understanding that the low pressure setting (EPAP) ...if set correctly... DOES indeed "treat" people. Repeat...it's not there just for comfort. The EPAP pressure is to prevent apneas. It needs to be set high enough to do just that.

EPAP serves the purpose of keeping the airway open during exhalation because less pressure is required to do that when we are exhaling.

More pressure is needed to do the same thing (keep the throat fully open) during inhalation, thus the IPAP is set higher.

khvn wrote: Note: I really don't care to be argumentative. It's just that right now I simply couldn't stand seeing my fellow cpap'ers being kept in the fog one more time in this issue regarding bilevels by the establishment.

It's physics and anatomy you are having a problem with. Not the "establishment."

khvn wrote:The low pressure setting (EPAP) in a bilevel is there for patient's comfort and does absolutely nothing to improve OSA treatment. At worst, it can even represent a weak spot that risks airway collapse. As such, for treating OSA, bilevels possess nothing more special or better than APAPs or even straight CPAPs.

Fortunately for me (and my sucessful treatment) your overly broad statement is wrong. I was prescribed a bi-level machine from the start for a very important reason. With straight cpap, when the required pressure was reached for eliminating episodes during inhalation it was too strong for my exhalation and would result in central apneas. For this reason no successful tritration using cpap was possible. But with a bi-level I am able to use the required inhalation pressure and a lower yet adequate exhalation pressure that stops events without causing central apneas.

Can the bi-level go to too low of a pressure to support the airway? Yes, if the lower range is set too low. I previously used the example where a lower recommended pressure allowed increased hypopneas, whereas returning it to the previous low setting eliminated them. The machine will not go lower than allowed, so will not create a threat of airway collapse if set correctly.

And if you think patient comfort has nothing to do with improving OSA treatment then you really know nothing about it and are probably not a user of any kind of cpap.

Great, so now I'm a troll. Someone has to have a pix of a mask-wearing troll CPAP'ing the night away under a bridge somewhere. ROFL...

OK, that's enough! Back to business! This troll's job is not done just yet!

Thank you BadBreath, yours is an absolutely solid piece of information. So a Bilevel did replace straight CPAP in your case. However, my "argument" (what else do you expect from a troll?) is still not dead in the water yet:

(1) Strictly for OSA treatment, bilevels are NOT better than APAPs

(2) The establishment want us to believe otherwise and keep us cpap'ers in the dark to make more money out of us.

It getting late. Troll must go hook up with mask. Y'all watch out, troll dreams up more outrageous flames tonight.

[quote="khvn"]Great, so now I'm a troll. Someone has to have a pix of a mask-wearing troll CPAP'ing the night away under a bridge somewhere. ROFL...

OK, that's enough! Back to business! This troll's job is not done just yet!

Thank you BadBreath, yours is an absolutely solid piece of information. So a Bilevel did replace straight CPAP in your case. However, my "argument" (what else do you expect from a troll?) is still not dead in the water yet:

(1) Strictly for OSA treatment, bilevels are NOT better than APAPs

(2) The establishment want us to believe otherwise and keep us cpap'ers in the dark to make more money out of us.

It getting late. Troll must go hook up with mask. Y'all watch out, troll dreams up more outrageous flames tonight.

And I hope Dr. K. will stay.

The 425 does give more than compliance data - but not any AHI data. I supposw that when a person know how an apnea or hypopnea is expressed in respiratory cycle and respiratory rates, they will know how their 425 treats them.

And you could explain that, Dr. Krakow, I know I'm not the only who will appreciate it.

O.

[quote="ozij"]And I hope Dr. K. will stay.

The 425 does give more than compliance data - but not any AHI data. I supposw that when a person know how an apnea or hypopnea is expressed in respiratory cycle and respiratory rates, they will know how their 425 treats them.

And you could explain that, Dr. Krakow, I know I'm not the only who will appreciate it.

O.

[quote="Snoredog"]

that sounds like my early 420S reports, it didn't give any AHI data either, could be mistaken but I don't recall it giving anything resembling the 96hr detailed report, which is what I think you would want to see if trying to resolve UARS and look for FL Runs. You could look at the cycle states, but my current cycle states on the 420e is very good at 97% most of the time I pull up a report.

So without that detailed data, you would be titrating yourself in the dark, so for that reason I would have to suggest the M series Bi-pap Auto, find your EPAP pressure that eliminates all your OSA apnea, that becomes your EPAP minimum, then allow the machine to increase IPAP

Thanks for above.

Hi Snoredog,

We have one of the smartest person in this forum that figured out about FL on the auto bipap long before anyone does or at least I thought so)....that is RESTED GIRL. Many did not asked in the forum but she was way ahead in this arena and I respect her in many ways. Must be the angel that god send to us........am still lerning each day.

Mckooi